Interactive effects between pregnancy-related alcohol policies and state spirits availability on infant and maternal outcomes

<i>Background:</i> Most state policies targeting pregnant people's alcohol use are ineffective, while some broader alcohol availability policies like government monopolies on retail spirits sales are effective. Previous research has not explored interactions of these policies.<i>Objective:</i> Analyze whether there are interactive effects between pregnancy-specific alcohol policies and government monopolies over retail spirits sales on infant and maternal outcomes.<i>Methods:</i> Outcome data were from Merative MarketScan®, a commercial insurance claims database, and included individuals who birthed singletons between 2006 and 2019 (<i>N</i> = 1,432,979 birthing person-infant pairs). We examined interactions between six pregnancy-specific policies and government monopolies. Regression models include (monopolyXpregnancy-specific policy) interaction terms, state and year fixed-effects, state-specific time trends, individual- and state-level controls, and clustering by state.<i>Results:</i> Associations of pregnancy-specific policies were generally stronger, or only present, in monopoly states. However, there was no consistent pattern regarding direction. Conversely, government monopolies consistently related to reduced infant maltreatment, with the largest effect when Priority Treatment for pregnant women policies were also in place [-1.64% (95% CI -1.87, -1.41)]. Protective associations of government monopolies on infant morbidities differed across reporting policies; for example, monopolies were protective without Reporting Requirements for child welfare [-0.28% (95% CI -0.40, -0.17)], but no longer protective with this policy [0.00% (95% CI -0.53, 0.55)].<i>Conclusions:</i> Government monopolies on retail spirits sales generally relate to reduced infant maltreatment and morbidities, although some pregnancy-specific alcohol policies blunt the protective effects of government monopolies. Repealing some ineffective pregnancy-specific policies - e.g. some Reporting Requirements - in monopoly states might improve infant outcomes.